C hapter 1

I ntroduCtIon

Step inside, you will always find a place

This book is written for all play therapists, regardless of their theoretical orientation or approach to play therapy. It is an integrative model that provides play therapists with a framework from which to conceptualize the play therapy process and evaluate their therapeutic interventions when working with children. This book also serves as a decision-making guide, offering various reference points for examining the who, what, when, why, and how of play therapy. As an integrative model, it is especially helpful to those therapists who work from an eclectic perspective, as it highlights the ways in which existing theories and techniques interact within two primary dimensions. Based on the assumption that each child seen in therapy is unique, which requires the play therapist to tailor interventions to the child, the Play Therapy Dimensions Model provides an organizing framework for decision making. Supervisors and supervisees will find the model invaluable as a framework for tracking the therapists use of self, examining the applications of theoretical models, movement in the play therapy process, and evaluating treatment progress. The book and accompanying DVD provide a breakdown visually and descriptively of the Play Therapy Dimensions Model. Included in this chapter are two detailed case studies that will help to familiarize the reader with the background and presenting concerns of the child clients who are represented in the DVD.

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P l ay T h e r a P y D i m e n s i o n s m o D e l

do

p l ay t h e r a p I s t s n e e d a n o r g a n I z I n g f r a m e w o r k ?

There is a growing tendency of eclecticism in the general field of psychotherapy, which simply means that practitioners are selecting from various theories those strategies and techniques that appear best for the client (Schaefer, 2003). A similar trend is occurring in the field of play therapy, paralleling the proliferation of theories and techniques. In a survey of play therapists, Phillips and Landreth (1995) found that an eclectic, multitheoretical orientation was, by far, the most common approach reported by respondents. While this indicates that many practitioners do not adhere to a purist, one-size-fits-all orientation, decisionmaking guidelines are lacking. A confounding factor is that if play therapists were truly multitheoretical, they would require a model for conceptualizing and monitoring the primary therapeutic change mechanisms. LaBauve, Watts and Kottman (2001), developed a tabular overview for approaches to play therapy in an attempt to assist play therapists to understand the basic tenets of contemporary play therapy approaches and to identify the focal points of change for each. This overview provides play therapists with a comparative framework for examining the similarities and differences of play therapy approaches. This summary provides a starting point for therapists who wish to adopt an integrative approach, as it helps identify the commonalities amongst various schools of play therapy. Even with a comparative overview, unless there is an organizing framework, the play therapist runs the risk of adopting an atheoretical approach to treatment, applying techniques in a haphazard manner which disregards underlying theory and ignores the importance of mediator and moderator variables. However, when an eclectic perspective is firmly placed within a decision-making model that offers a clear conceptualization of the change mechanisms, the practitioner can flexibly and mindfully operate within a number of schools of play therapy. In a therapeutic climate that increasingly focuses on time-limited and evidence-based treatments, many would argue that there is mounting pressure to become goal-focused at the expense of acknowledging the childs inner direction and drive as a central feature of the play therapy process. Others suggest that play therapists should develop practice guidelines and matching specific treatment interventions to referral problems, based on available empirical studies (Schaefer, 2003). Currently, research lends support to the use of play therapy across a range of presenting problems. For example, LeBlanc and Ritchie (1999) conducted a meta-analysis of play therapy research, indicating that play therapy was an effective intervention regardless of the presenting problem of the child. The results suggested that two primary variables have an impact on the efficacy of play therapy: the involvement of parents in the play therapy process, and the

20

IntroductIon

number of therapy sessions. Bratton and Ray (2000) examined over 100 case studies documenting the efficacy of play therapy. They reported that participants consistently demonstrated more positive behavior and fewer symptomatic issues after play therapy interventions, as compared to their behavior before the play therapy interventions. A limitation of these studies is controlling the complex clienttherapisttreatment interaction. As noted by Schaefer (2003), what lies at the core of this issue is our ability to define the underlying change mechanisms in successful play therapy, as well as client and therapist variables that influence treatment. This does not mean that therapists should refrain from anchoring their work to one school or model of play therapy. However, what links us together is an understanding of the importance of the therapeutic process and the underlying change mechanisms. As noted by Schaefer (2003): Change mechanisms are not theoriesthey are descriptions of observed relationships. They are more general than techniques and they are more specific than theories. They are the ifthe relationships that tell us when to do, what to do and whom to do it to. (p.309) The Play Therapy Dimensions Model assists the practitioner to consider the complexities inherent in change mechanisms, and encourages decision making concerning the possible applications of a number of theoretical approaches and techniques, tailoring these to the child. In the field of play therapy it has long been recognized that play, in itself, will not ordinarily produce changes for hurt or troubled children. Rather, it is the therapists interventions and utilizations of the play that are critical (Chethik, 2000). How the therapist and child share the therapeutic space is central to many models of play therapy. In some models, such as Cattanachs (1992) multi-dimensional model of play therapy for working with abused children, this space is viewed as the transitional space between the child and therapist. It is described as a psychic space in keeping with Winnicotts (1971) views where the child discovers the self, and the space is used to define me and not me. In child-centered models, the use of the relationship is a defining characteristic of this space (Landreth, 2002). In other models, the use of this space and the underlying change mechanisms are conceptualized in substantially different ways. For instance, in Adlerian Play Therapy emphasis is placed on building a relationship, as well as reorienting and re-educating the child, helping them gain insight into their lifestyle (Kottman, 2003b). In this therapeutic context, the role of the Adlerian therapist is described as active and directive. Commonalities in goals and principles exist across the various models of play therapy. For instance, Wilson, Kendrick and Ryan (1992) point out that there

21

P l ay T h e r a P y D i m e n s i o n s m o D e l

is general recognition that play therapy occurs in the context of a therapeutic relationship and that the function and symbolic meaning of childrens play is central to the way children express their wishes, fantasies, conflicts and perceptions of the world. Further, there is widespread agreement that play therapy often provides a corrective emotional experience for children, along with opportunities to develop mastery over disowned feelings. These results follow from what many recognize to be the major therapeutic powers of play, such as its communication power, its teaching power, its ego-boosting power and the propensity for self-actualization through the safety and freedom to be oneself in play (Schaefer, 2003). Unfortunately, debate continues to surface over the correctness of one model over another, placing the practitioner in the position of choosing one approach over another at the expense of losing sight of the child as well as the therapists own personal orientations toward psychotherapy. The latter factor must not be underestimated; many would argue that the personal fit between the individual therapist and the theoretical approach is critical to the successful implementation of that approach (Cattanach, 2003; Landreth, 2002). While an integrative approach to play therapy is of great value in guiding and informing our practice, it is simply not enough to ensure effective practice. Play therapists work in various settings and are often part of a collaborative team. In this context they are in a position to offer unique insights and understanding of the child or family system. This speaks to the need for the play therapist to have a solid understanding of other therapeutic modalities as well as a firm grounding in child development. Most important, the play therapist needs to constantly work on knowing her/himself and use that self-understanding in the most appropriate and meaningful ways, therapeutically. Accordingly, it is assumed that most readers will have extensive academic background and experiential training in areas related to child development and family work. It is also assumed that as a practitioner in play therapy the reader will be familiar with various theoretical approaches to play therapy and is actively involved in a supervision process; if acting as a supervisor, it is assumed that a range of support mechanisms and monitoring tools are in place. To strengthen practitioner and supervisory skills, this book provides a number of tools for self-development and supervision.

I n t e g r at I v e

p l ay t h e r a p y : t h e n e e d f o r a

framework for deCIsIon makIng

There has been much written in the adult psychotherapy literature about integrative approaches to therapy. Through the 1970s there was a proliferation of writing that contributed to the thinking about what the terms integrative or (as many

22

IntroductIon

described themselves) eclectic mean. Eclecticism was harshly criticized as a hodgepodge of inconsistent concepts and techniques (Smith, 1982, p.802). The random use of techniques and theory was discouraged. At the same time the use of a single school of practice was also viewed as being limited. Integrative therapy is considered to be a purposeful weaving of theory, techniques and common factors identified across therapies (Norcross, 2005). Although being integrative requires an approach and a way to decide how to work with a client, Garfield (1994) noted that those who described their work with clients as integrative said that they followed what was best for their clients, but described differing decision-making processes and differing theories and techniques from one another. Even with the current availability of defined integrative practice approaches, it would appear that there is not enough outcome research that shows what integrative therapists do and if what they do is really that different to purist therapists (Garfield, 1994; Glass, Victor and Arnkoff, 1993). The question is, Do integrative therapists follow a decision-making model for their client work and if so what is it? The current status is that there are four main approaches of psychotherapy integration in the adult psychotherapy literature: 1. Common factors approach which focuses on the common underlying factors shared by different therapies which generally include catharsis, acquisition and practice of new behaviors, and the clients positive expectancies (Grencavage and Norcross, 1990). 2. Technical integration which is prescriptive in nature in that it focuses on the best treatment for the client and the presenting problem. The treatment choice is based on research about others who present with similar issues (Lazarus, 1976). 3. Theoretical integration, which draws on two or more theoretical approaches to therapy. Essentially, the practitioner attempts to weave different theories and techniques together to best serve the client[AQ]. 4. Assimilative integration which is when the therapist begins with their core training approach to therapy, but they may borrow or select from other approaches to incorporate a new way of working with the client. The therapist is viewed as grounded in a theory while being flexible in their use of a range of other theories and techniques, perhaps creating new ways of working (Norcross, 2005). Much of the play therapy literature on integrative approaches to therapy is anchored in reported case studies. This being said, some play therapists appear

23

P l ay T h e r a P y D i m e n s i o n s m o D e l

to be making use (knowingly or not) of the above integrative approaches to working with children. Drewes (2011) identified Kenny and Winicks (2000) use of technical eclecticism with an 11-year-old autistic girl where a sequential treatment approach was utilized; Kevin OConnors (2001) use of ecosystemic play therapy was noted as an example of theoretical integration where he incorporates components of analytic, child-centered, cognitive, Theraplay (Jernberg, 1979) theories as well as concepts of personality and psychopathology in his treatment planning and goal setting; Weirs (2008) use of common factors in work with an adoptive family where commonalities across play therapy treatment techniques for Reactive Attachment Disorder were utilized; and Falls (2001) case study using assimilated integration to treat a child in a school setting. Fall used the core theory of child-centered play therapy, but blended this approach with Adlerian and cognitive behavioral theories and techniques. Following the common factors approach to integrative therapy Drewes (2011) points out that (in addition to therapeutic alliance, opportunity for catharsis, acquisition and practice of new behaviors and the clients positive expectations) (Grencavage and Norcross, 1990) play therapists should consider the therapeutic powers of play in work with children. Drewes (2011) included potential change agent factors such as: self-expression, access to the unconscious, direct/indirect teaching, abreaction, stress inoculation, counterconditioning of negative affect, positive affect, sublimation, attachment and relationship enhancement, moral judgment, empathy, power/control, competence and self-control, creative problem solving, fantasy compensation and reality testing. (p.29) Identifying common factors across theoretical approaches to play therapy is still in process. More research will be needed to unveil commonalities. Schaefer (1999) supports the notion that the curative factors and change mechanisms in work with children are highly important to the overall effectiveness of the therapy. This being said, it would be important to examine common factors that lead to change in play therapy and any other intervening variables that increase treatment effectiveness. Are play therapists moving closer towards integrative thinking? Rapid theory development may be encouraging play therapists to think in integrative ways. Learning a theory or two, however, does not make an integrative play therapist. There are now over 25 approaches to play therapy and counting. It has already become overwhelming for students of play therapy to incorporate the multiple ways there are to work with children. Many play therapists who attend the Rocky Mountain Play Therapy Institute arrive for training without

24

IntroductIon

a core training approach to play therapy. While at the Institute they receive an overview of at least 12 models of play therapy with a practice/experiential focus on at least three models. This is for some, the first exposure to the variety of ways in which play therapists approach therapy. There is little encouragement to seek comprehensive training as the play therapy associations continue to accept hours earned at workshops that have been cobbled together to count as hours towards formal play therapy training requirements for certification. An eclectic approach to training will likely lead the play therapist to learn about one or two models of play therapy and a variety of techniques. The problem with this approach to training in the private sector or in universities is that, as Drewes (2011) states: Therefore, students graduating will call themselves eclectic, but what they are really saying is that they have been taught two different approaches (usually cognitive behavioral and Rogerian). Consequently, they are not fluid in thinking between the two theories and approaches and they do not feel well-grounded in either approach, resulting in an inability to truly integrate them. Thus, a truly integrative approach is lacking. (p.33) Those who have been trained in a pure play therapy approach in a university setting are few as there are not many comprehensive programs offered. Those who have come from a specific play therapy model of training tend to be clustered geographically due to living near training centers or universities that offer full training programs such as North Texas University. Otherwise, it is more often that those seeking training in play therapy arrive with their adult-focused academic training backgrounds, many of which have been influenced by postmodernism. These therapists generally claim to be eclectic practitioners. Coscolla et al. (2006) make the controversial claim that historically psychotherapies were developed during a culture of modernity and there has been a cultural shift to postmodernism and that this influences the psychotherapists attitudes regarding theory. They state that eclecticism is postmodern and that integration has roots in modernism. Coscolla et al. use the work of Norcross and Newman (1992) to delineate the ways the two words are characterized. The terms used to describe integration include a belief in theory, a seeking to find agreement between theories, and a focus on developing better approaches and legitimization through scientific methods while eclecticism focuses on functionality, no grand narratives, everything goes and it is based on clinical needs. This is one conceptualization and there are others who may find different anchors to differentiate the two terms. It is an interesting discussion as we are in the midst of cultural change in the ways we philosophically view the world and how we go about understanding problems, processes, approaches and outcomes in therapy.

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P l ay T h e r a P y D i m e n s i o n s m o D e l

No matter what theory, approach, model, or worldview you come from, decision-making frameworks are lacking for integrative therapists. As previously noted, there are at least four approaches for integrative therapists who work with adults, which provide basic guidance without providing standard approaches to decision making. However, the ways in which the integrative approaches are viewed differ greatly from therapist to therapist. Stricker (2010) argues that the current categorizations for integrative therapies (although helpful) have blurry boundaries for research purposes. The more detail that is put forward, the more complex and hazy the boundaries between the integrative approaches become. Sticker claims that there may be two ways to move ahead: 1) expand the categories or 2) abandon the categories. In other words provide more clarification categorically or simplify the way to view integrative therapy. Practitioners and researchers are looking for ways to explore integrative therapy in order to identify common pathways to this way of working with clients. Without a decision-making process that is relatively standard, integrative play therapy may continue to be at risk of slipping back to looking more like eclecticism.

p l ay

therapy dImensIons model: a deCIsIon

g u I d e f o r I n t e g r at I v e p l ay t h e r a p I s t s

The Play Therapy Dimensions Model provides a fluid process for decision making. There are a number of scales and tools for the play therapist to use to track their continual decision-making process. These tools provide all play therapists a way to identify and manage their on-going clinical decisions. The attached appendices (Appendices A, B, and C) assist in regular systematic tracking. One of the main obstacles to research in integrative therapy is that integrative psychotherapy can be highly complex and that decisions regarding treatment are being made on a continual basis throughout therapy (Beutler, Consoli and Williams, 1995). Beutler et al. (1995) also note that the client characteristics change over the course of treatment, which shifts the way in which treatment is delivered. The Child and Therapist Moderating Factors Scale (Appendix A) helps the play therapist to track these on-going shifts and changes in their child client. Appendix A also tracks the child and therapist treatment interaction factors. The Degree of Immersion: Therapist Use of Self Scale (Appendix B) tracks session by session ways the therapist makes use of the self with the client and also asks for a description of the clients response to the therapists use of self. Because the tool is not about techniques, it helps a range of play therapists to be aware of the how of the process rather that the what. Additionally, Figures 1.1, 2.1 and 2.2 [AQ]provide a visual template of the dimensions of consciousness and directiveness, which

26

IntroductIon

assist the therapist to identify therapeutic movement during sessions and across sessions. Visual mapping of therapy activities raises the awareness of the presence of integrative play therapy decision making. The Play Therapy Dimensions Model is useful for qualitative, quantitative or mixed-methods research due to the establishment of a way of systematic recording of the play therapy processes at four levels: 1) child characteristics 2) therapist characteristics (including therapist skill level) 3) therapist use of self (and corresponding child client responses), and 4) session tracking and observation form (including play skills, identification of work in consiousness and directiveness dimensions, development, play process, relational and affective markers, play themes and a summary). Each of the recording forms looks at a different part of the play therapy process and identifies when changes in direction, intensity, directiveness or consciousness in play therapy should shift. How does the therapist decide to be more integrative? The child client directs the changes (verbally, non-verbally or metaphorically through the play). Although adult models of therapy have addressed a client-driven focus (Miller, Duncan and Hubble, 2005) whereby the wishes and needs of the client ascend the theoretical and technical approaches of the therapist, this has not been as clearly identified in the child therapy literature. A possible explanation for this difference is due to the developmental and inherent power differences between the therapist and child and the assumption that the child cannot express him- or herself in the ways an adult client can.

how

d o I n t e g r at I v e t h e r a p I s t s m a k e d e C I s I o n s ?

There is no research to support whether therapists consciously shift from utilizing a primary model of therapy to working in an integrative way (Schottenbauer, Glass and Arnkoff, 2007). Specific guideance in therapeutic decision making was one of the goals of the Play Therapy Dimensions Model for those working with children. In the adult literature, authors concur that a common theory for decision-making processes for therapists would be valuable (Beutler and Clarkin, 1990; Beutler et al., 1995; Street, Niederehe and Lebowitz, 2000), but currently there is no common adult based decision-making process for psychotherapists. Schottenbauer et al. (2007) note that there are a few factors that assist the adult therapist to make decisions to be more integrative such as if the client becomes stuck during treatment or if the therapist thinks there is a more efficient way to meet the same goals to cut the cost of therapy or as Marmar (1990) adds individual patient differences, phase of therapy, patient state, patient capacity for absorption of process, or related contextual problems (p.267) may influence more integrative ways of working with a client. The Play Therapy Dimensions Model is based

27

P l ay T h e r a P y D i m e n s i o n s m o D e l

on these types of contextual considerations for the child client. We concur with Zuber (2000) who refers to patients varied ways of describing their problems, which in turn affects the decision making of the therapist regarding how to work with the patient. The importance of client input regarding clinical intervention is highlighted. The same thinking can be applied to work with children, except their explanations of their problems are presented in verbal, non-verbal and metaphorical ways in play and their input is often more non-verbal. Early on we realized the skill set for the play therapist needed to be broadened from that of being an adult therapist to working with children. Therapists needed assistance to know what they were looking for in their work with the child so that they could address the unique presentations and preferences of the child. Otherwise, the therapy interventions would likely be driven by therapist preferences and parent or third-party expectations.

do

a d u lt s f I t f o r p l ay t h e r a p I s t s ?

deCIsIon-makIng theorIes desIgned for

There are well-known and emerging decision-making theoretical frameworks for adult integrative therapists. The well-known subjective utility theory consists of analyzing decisions by reviewing all possible outcomes, assigning probabilities to each and choosing the best decisions with which to proceed. The problem with this approach is that it is biased, it can be overly inclusive, it is not based in the moment and therapeutic decision making is not always a rational task to be sorted in advance of the process (Schottenbauer et al., 2007). Emerging decision-making approaches identified by Schottenbauer et al., include, information-processing theory and bounded rationality theory. Information-processing theory uses symbolic and qualitative reasoning derived from transcripts from therapists that provides, as Elstein (1988) states, what knowledge structures, cognitive operations, and rule structures are necessary and sufficient to produce clinical reasoning (p.19). Through this analysis, therapists may be able to understand how their original theoretical orientation and the theories and techniques that were brought in to the therapy interact. Schottenbauer et al. ponder whether clinicians using psychotherapy integration use more strategies, or more complex strategies, than clinicians using pure-form therapies (2007, p.233). Bounded rationality (although not a new construct) as discussed by Gigerenzer (2001) is a decision-making process that takes note of the practical limitations for therapists such as resources, time and knowledge and computational capacities which differs from the boundlessness of utility theory. The term satisficing is used

28

IntroductIon

to describe the process of gathering information in a timely way and making decisions. The decisions are made using search rules (determining alternative actions and gathering cues), stopping rules (one or more criteria is met before a search for alternatives is sought and different course of action or decision is made). Medical model diagnostics use stopping rules by listing criteria or characteristics to choose from in order to make a diagnosis or move on to another way of viewing the client situation. Decision rules are made based on heuristics and on the limitations of time and information available about the client. The theory of bounded rationality considers three basic elements relevant to the decision-making task: psychological plausibility, ecological rationality and domain specificity (Schottenbauer et al., 2007, p.235). Psychological plausibility is a reasoning process that takes into consideration the therapists cognitive and emotional factors that contribute to decision making when time, knowledge and computational capacity is limited. The review by Schottenbauer et al., (2007) is of interest as they comment on the emotional factors that play a part in decision making. It stands to reason that therapist use of selfevaluation must be included in a conscious way, which is (in part) why Appendix B (Degree of Immersion: Therapist Use of Self Scale) was developed. If therapist emotionality is viewed as one of the decision-making factors, the therapist must make sense as to how he/she is making use of him/herself. Seymour (2011) points out: Considering the importance of therapist factors identified in common factors research, one possible method would be to include the incorporation of self of therapist work with studies on integrative psychotherapy (p.13). Ecological rationality describes a decision-making element that meets the environmental situation. Because play therapists work with children, parents and systems, there is a continual interaction between the therapist, the client and client system. Constant adjustment to the environment and the needs of the client is necessary. The Play Therapy Dimensions Model provides a method for the therapist to collect this information through a tracking system. This frees the therapist to move freely in the moment and to evaluate the process along the way. Appendix A (Child and Therapist Moderating Factors Scale) helps the therapist to evaluate child characteristics, therapist characteristics and the interactions between them. The focus on client characteristics can assist the integrative play therapist to be discerning about the techniques they choose to use. Schottenbauer et al.s (2007) reflections on the work of Beutler and Martin (2000): More recent research has shown that variables relevant to choosing therapeutic techniques can be grouped into four categories, including patient predisposing variable, treatment context, relationship qualities and interventions, and selection of the strategies and techniques that best fit the patient (p.230).

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P l ay T h e r a P y D i m e n s i o n s m o D e l

According to Schottenbauer et al., domain specificity is related to how assessment and treatment generalizes from client to client and focuses on the degree of therapist integration. Domain specificity is based on heuristics and tailoring approaches of therapy to the client. Domain specificity is addressed in the Play Therapy Dimensions Model. Appendix C (Tracking and Observation Form) is more than just a checklist, as it leads the therapist through a number of considerations that allow for deeper conceptualization, client to client. Comparing various client profiles and clinical interventions as related to presenting issues is possible with this tool. Play therapists who regularly use the tool deepen their conceptualizing ability and increase their ability to tailor their interventions in a more effective, less time-consuming way with their child clients. The above decision-making theories may be familiar to play therapists due to initial training exposure to therapy with adults. The theories provide useful guidelines for therapists to draw on when considering integrative play therapy. Of particular interest to us is how these theories fit with the Play Therapy Dimensions Models structured tools. The bounded rationality theory of decision making appears to offer some theoretical direction to the Play Therapy Dimensions Model decision-making structures. The difference that theory makes is that it suggests where to focus. The point that bounded rationality theory makes is that therapists could not possibly process all the information about a person or situationeven if they had access to it all. Given time and different pieces of information a person may make different decisions, but they would still have to select among information and use some rules to do so. Bounded rationality theory supports the development of techniques, habits and standard operating procedures to facilitate decision making. The theory also sheds light on the cues therapists use to consider one direction over another in their work with clients. Elements of the theory appear to drive the intended use of the Play Therapy Dimensions Model structured tools. The therapist can optimize their treatment decisions through the on-going recording of observations of self and other, the tracking of the play therapy process across the dimensions of consciousness and directiveness and the therapeutic interaction between these areas. Generally, we have found play therapists bring a wide variety of therapy skills and experience to their work with children. As trainers, what became clear was that it was difficult for play therapists to hold and later process the incoming information gathered during play therapy sessions without the use of tools to anchor their experience. Therapists needed a way to observe and record the play therapy process in order to feel that they could evaluate the decisions they were making (either intuitively or consciously). The result of consistent use of the structured forms is that therapists began to make better decisions because they had a framework through which to evaluate their work. They could get feedback

30

IntroductIon

in supervision in ways they could not otherwise once they could use a shared language with which to speak to the supervisor about what was happening. They could make better plans and provide broader feedback to third parties. The best part of the process is that the Play Therapy Dimensions Model found a way to be inclusive to all theories and models of play therapy. In summary, it is not necessary to practice as an Integrative Play Therapist, but it is important to know when you shift to work with a child in an integrative way. It is equally important to look to the literature to identify an approach to integrative therapy and to identify your decision-making theory. The Play Therapy Dimensions Model provides a number of tools and structured forms (see Appendix A, B, and C), as well as a conceptualization diagram (see Figure 1.1 [AQ ]), to assist you to be systematic in your work with children. The information gathered on these tools may also be used for evaluative or research purposes. It will not matter what approach to integration you choose, the structure will help you become a more effective practitioner and decision-maker.

w h at

Is the

p l ay t h e r a p y d I m e n s I o n s m o d e l ?

While recognizing that there are fundamental philosophical differences between schools of play therapy, as well as shared viewpoints, the Play Therapy Dimensions Model conceptualizes the play therapy process according to two primary dimensions: directiveness and consciousness. These dimensions help define the therapeutic space in a manner that most practitioners will recognize as fundamental to the change process. The consciousness dimension reflects the childs representation of consciousness in play, and is represented by the childs play activities and verbalizations. The second dimension, directiveness, refers to the degree of immersion and level of interpretation of the play therapist. As represented in Figure 1.1, the Play Therapy Dimensions Diagram, these two dimensions intersect, forming four quadrants. Depending on the case conceptualization, and the theoretical approach of the therapist, a therapist might choose to focus therapy activities primarily in one quadrant. Alternatively, there may be a number of indicators that suggest movement is required amongst the quadrants. Furthermore, movement may occur within a session, or across sessions, as the therapy process evolves. As will be discussed, this conceptualization assists therapists in navigating the complex clienttherapisttreatment interactions in order to tailor treatment approaches and optimize effectiveness. This integrative approach also offers a process-oriented framework, providing guidance for tracking important change mechanisms. The model will appeal to those individual treatment-focused practitioners as well as those who are practicing from a systemic framework. It is our view that

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P l ay T h e r a P y D i m e n s i o n s m o D e l

play therapy in itself is an efficacious form of treatment and is most productively embedded in parent work and systems-based consultations and interventions. It is a widely held belief that parents should contribute to the formulation of goals for therapy and must be informed as to treatment progress. Through helping parents learn more effective ways to deal with their childs emotional needs, personality, and developmental or adjustment issues, therapists can secure their support and enhance therapeutic outcomes (McGuire and McGuire, 2001). Although it is beyond the scope of this book to discuss these facets of treatment in detail, they are highlighted through anecdotal case examples.
Consciousness

I Active utilization NonDirectiveness III Non-intrusive responding

II Open discussion and exploration Directiveness IV Co-facilitation

Unconsciousness F I g u r e 1.1: Play Therapy Dimensions Diagram

about

thIs book

Chapter 2 provides an overview of the Play Therapy Dimensions Model. Chapters 3 and 4 outline important theoretical constructs in relation to the consciousness and directiveness dimensions, placing each of these in a context for decision making by integrative play therapists. Chapters 5 to 8 are dedicated to a description of each of the four quadrants: non-intrusive responding, co-facilitation, active utilization, and open discussion and exploration. Chapter descriptions are organized in such a way that therapists can answer the who, what, when, why, and how questions for each quadrant. In each of the chapters describing the quadrants, six indicators help therapists to decide whether they should stay working in a particular quadrant, or they should go. Additionally Chapters 5 to 8 refer directly to the DVD case

32

IntroductIon

examples and describe the therapist activities and child responses when working in each quadrant. The quadrants are presented in the order in which they occur on the DVD so that the reader can follow the therapy sequence. Because the Play Therapy Dimensions Model is an integrative approach to play therapy, it is a sound supervision tool. Chapter 9 is dedicated to the use of this model in supervision. Play therapists and play therapist supervisors are given introductions on how to use the DVD in clinical supervision, how to aid supervisees in making [AQ]videotapes, and how to use the model to review the videotapes[AQ]. A specific, developmental model of supervision for play therapists is presented and bridging activities for the supervisee and supervisor are discussed for each phase of play therapy development. Chapter 10 examines the therapist use of self, and raises the play therapists awareness to the various ways one makes use of the self in a play therapy session. Further direction is provided for using the Degree of Immersion: Therapist Use of Self Scale (Appendix B), by examining in detail five areas of immersion. Knowing yourself is an essential underpinning to working with people, but in working with children, your inner child is instantly awakened and present during therapy sessions. We believe this work cannot be done without significant self-exploration due to the fact that working with children triggers another level of emotional and spiritual vulnerability. Chapter 11 outlines a number of critical matters worth exploring such as: know yourself and your temperament, know yourself culturally and ethnically, know yourself when working with parents. Issues related to vicarious trauma and the importance of making meaning in therapy are also explored in Chapter 11. Chapter 12 emphasizes the invitation to unite all play therapists by finding a unifying point of reference. We believe the Play Therapy Dimensions Model does just that. Metaphorically, it is the table that ensures all play therapists have a place setting from which to enter into clinical conversations. We are not interested in debating the therapeutic ways to being and intervening with children, rather we are focused on increasing inclusiveness and becoming more collaborative. There are a variety of ways to understand play therapy that only increases our field of vision. The book offers four specific tools to aid play therapists in their professional development. Therapists can use the tools, regardless of their phase of development. The Child and Therapist Moderating Factors Scale (Appendix A) helps the therapist to identify client and therapist mediating factors in order to appropriately plan, set goals and intervene with clients. The Degree of Immersion: Therapist Use of Self Scale (Appendix B) helps play therapists rate the ways and degrees in which they immerse themselves in a given play therapy session. Therapists can evaluate the client response in relation to their immersion and

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subsequently make decisions as to whether the use of self should alter or stay the same. The Tracking and Observation Form (Appendix C) is helpful for therapists to use after each play session. It assists therapists to evaluate: the developmental stage of play; play process including initiation of play activities, play capacity, inhibitions/disruptions and endings; relational and affective markers including emotional range, self-regulation, and engagement; and thematic representations. The Playtime Exercise (Appendix D), is a self-exploration exercise that helps the play therapists to examine their personal history of playboth individually and with their families of origin. This book and DVD introduces readers to the possibility of movement along the two primary dimensions. Therapists working from specific theoretical orientations may have chosen different entry points and may have fostered movement at different points, for various reasons. This simply reflects the art of therapy. By offering a decision-making guide that is mapped onto two dimensions, the play therapist may escape what Norcross (1987) refers to as kitchen-sink eclecticism. Therapists will expand their theoretical frame and repertoire of interventions by utilizing the Play Therapy Dimensions Model.

Case

studIes

Models tend to remain academic exercises unless they are brought to life and a therapist can see how the model is implemented. To this end, the accompanying one-hour instructional DVD includes two case studies. The first case of a nineyear-old boy named Ellis, demonstrates each quadrant of the Play Therapy Dimensions Model through four brief play segments, lasting five to ten minutes each. The segments are chronologically ordered, representing what therapy might look like if one were working with Ellis over the course of several play sessions. This unique view through the playroom window allows us to observe movement across play sessions, in conjunction with hearing about the underlying decisionmaking points that contributed to movement amongst the four quadrants. The second case illustrates a single session in a condensed format lasting approximately 30 minutes. The young person is a ten-year-old girl named Haley. This case offers a different view through the playroom window, one in which the play therapist constantly tracks the play and, at certain points, strategically moves along the play dimensions. The decision-making points and outcomes of movement are discussed in the context of the Play Therapy Dimensions Model. To establish an understanding of the context for the referral issues and the accompanying therapeutic goals, detailed case descriptions are provided below for each child.

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DVD case study: Ellis

PreSenTing Problem Ellis is a nine-year-old, Grade 4 student referred to therapy by his mother, Donna. During the telephone intake interview Donna reported that she and her husband, Don, have three children. Ellis is the middle child; there is a younger four-yearold brother, Sam, and an older 12-year-old sister, Janet. Donna reported that Ellis had become increasingly destructive and angry at home. For example, Donna reported that Ellis broke several of his own toys when he could not get one to work. She further noted that Don observed Ellis yelling at teammates on his baseball team, claiming this was very uncharacteristic of Ellis. Furthermore, a teacher who has had Ellis in her class for the past two years recently reported that Ellis has been bossy with certain peers and seemed to overreact to helpful feedback from adults. It was also the teachers impression that Ellis appeared unusually angry. Historically, Donna indicated that Ellis was usually cooperative and accepting of rules and routines. However, lately Donna had noticed that Ellis was frequently argumentative and somewhat challenging of her authority. While this is less obvious during interactions with his father, Donna emphasized that Ellis has always had a special relationship with Don as he enjoys many of the guy things they do, such as repairing household items or tinkering in the garage. Given his age, Ellis spends little time playing with his younger brother, although he was described as generally behaving in a kind and gentle manner toward him. Donna reported that Ellis and Janet seldom play together. However, Donna noted that their relationship is a positive one, emphasizing that Ellis sometimes looks up to his older sister. As Ellis is bussed to school, he has a separate group of friends near home that he plays with regularly. While Donna indicated that Ellis has never had a best friend, she said that he seemed to be well liked by his age mates. Ellis had two fairly close friends at school. Unfortunately, both children moved last year, and Ellis has yet to report that he has a consistent group of friends that he plays with this year. Compounding this was a recent report from school that Ellis had been subjected to bullying on at least three occasions. On the first occasion Ellis was cornered in a washroom stall and two children refused to let him out. Another student reported the incident to a teacher as he heard Ellis crying. The two playground incidents involved physical pushing and teasing. Both times, a group of three students, all of who were older and bigger than Ellis, ganged up on him. While immediate steps were taken to sort out these issues, Ellis soon began to report that he didnt like school. During the intake interview Donna reported that Ellis had not reached a point where he outwardly refused to get on the school bus each morning. However, Donna was

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concerned that Ellis was very slow at getting himself ready for school and seemed to be stalling during every step of his morning routines. A primary concern raised by Donna was that Ellis had never been very talkative when it came to expressing or sharing his feelings. To repeated questions concerning why he seemed to get upset so easily, or why he argued, Ellis often responded, I dont know. Given this context, Donna requested that Ellis be seen individually for play therapy. Donna also asked that she and Don be included in a parent consultation process to strengthen and support their parenting strategies. When asked about specific desired outcomes for therapy, Donna identified the following three goals: 1. to help Ellis identify and cope with a range of feelings, including anger and frustration 2. to examine the impact of incidents of teasing and bullying at school 3. to assist Ellis in expressing his feelings.
backgrounD Donna and Don reported they were both employed on a full-time basis. No significant changes in family life were reported. Further, Don and Donna reported low levels of stress in their parenting and work roles. Don was actively involved in coaching sport activities and had been Ellis soccer coach for the last two seasons. Donna regularly volunteered at Ellis school and had accompanied his class on several outings. Ellis delivery was described as normal. As an infant and toddler, Ellis had frequent ear infections. Donna remembered Ellis as a loving and active infant and toddler, but also a colicky one. His early motor skills, such as sitting up, crawling, and learning to walk, developed normally. Ellis early language development, such as first words, asking simple questions, and talking in sentences, seemed to be typical. Ellis attended preschool, beginning at age four. He seemed to learn things at about the same rate as other children. No unusual or atypical behavior management problems were recalled for this time period. However, Donna reported that Ellis seemed to have more difficulty developing social skills than most other children. At the point of referral Donna described Ellis as angry and aggressive as well as somewhat perfectionistic. While Donna described Ellis mood as typical of others his age, she said that he shows intensely high levels of energy followed by periods of anger or sadness. Donna also commented that Ellis is somewhat small for his age. As Ellis seems to be very sensitive about this issue, and has been teased about his size, Donna now wonders whether Ellis struggles with feelings of low

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self-esteem. In support of this, Donna overheard Ellis tell his grandparents that he wanted to be the biggest student in his class, remarking, then no one would pick on me! During a modified play-history interview, Don and Donna indicated that Ellis was a very imaginative and creative individual who enjoyed activities such as playing cars and building with Lego. As Ellis is an active child, they noted that he also enjoyed outside, rough-and-tumble play activities with Don. Although Ellis has a tree house and used to have friends over to play fantasy war games, Don and Donna report that this stopped abruptly, equating this to the time that Ellis was being bullied at school. Prior to this time, Ellis seemed to take an active role when playing with other children in his neighbourhood. For instance, Donna remarked that Ellis used to phone other children and invite them over to play. Finally, a discussion about Ellis emotional adjustment indicated that he has always displayed an independent-style. Don elaborated on this by stating that if Ellis really didnt like what the other kids were playing, and couldnt convince them to try things his way, he would either move on and play with other children or engage in his preferred play activity alone. Donna emphasized that Ellis tendency for self-direction is a strength, although he never appeared to take advantage or dominate other children in play. During the initial parent consultation Donna and Don were shown the play therapy rooms. Don remarked that Ellis might find certain activities, such as puppets, boring or childish. Accordingly, the therapist took additional time to learn about Ellis play interests and capacities. The therapist also provided Donna and Don with an overview of the play therapy process, highlighting the parent consultation process as well as the nature of the parents involvement in treatment activities. At the end of the meeting, ideas were jointly discussed concerning how the parents could prepare Ellis for coming to play therapy.
iniTial imPreSSionS During the first session Ellis sat by himself, fidgeting with his hands. Donna was the initial spokesperson for the family, commenting that Ellis was unsure about coming to meet the therapist. The therapist openly acknowledged Ellis feeling of uncertainty and then briefly provided a framework to help Ellis get a sense of what might unfold. As planned, the therapist stated that when Ellis parents met with her they wondered how it was that children and parents could raise their fun-meter. This wording appeared to grab Ellis attention; the therapist then quickly demonstrated with her arms a gauge-like meter, emphasizing that it could go up and down, or sometimes could become stuck. Next, the therapist had family members guess where each other were on the fun-meter, using their arms

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as gauges. Ellis immediately asked to go first. In making a gauge representing his fathers fun-meter, Ellis placed his gauge in the high range, remarking that it went up because his father just got a new tool for woodworking. The discussion soon moved toward fun experiences for each family member. As Don and Donna were prepared for this analogy, they also asked the question of what people do when their fun-meter becomes stuck. When asked in which ways they noticed the fun-meter getting stuck, Donna stated that she thought Ellis meter became stuck after he was bullied at school. This provided an opening for the therapist to briefly comment on what other kids had told her about such experiences. She also emphasized that these same children were able to get unstuck through play activities they did together. This idea seemed to intrigue Ellis. The therapist elaborated that the playroom was a place where children get to try out all sorts of ideas and activities. During this animated discussion Ellis began to shift his focus to the various play objects in the therapists office. Within a few minutes Ellis asked, So do kids get to go to the playroom right away? The therapist inquired if Ellis would like to go and look around the playroom, to which he immediately said, yes. After a cautious start, it appeared that Ellis was ready to begin his journey in play therapy.

DVD case study: Haley

PreSenTing Problem Haley is a ten-year-old, Grade 5 student. Sarah, Haleys mother, referred her to therapy after school staff alerted Sarah that Haley appeared increasingly withdrawn and seemed reluctant to go outside for recess. Teachers reported that Haley seemed lost and preoccupied. Although Haley has always been a strong student academically, teachers noted that she was completing less schoolwork during class and frequently made errors. At home, Haley was described as a quiet child who spent long periods of time playing alone in her room. Although Haley had always enjoyed playing with her six-year-old brother, Jonathon, Haley had recently become bossy and controlling in her play. Sarah noted that this was uncharacteristic of Haley, and the situation had reached the point where Jonathon often came crying to Sarah stating, Haley is being mean again. Sarah reported that Haley had never been a discipline problem. During the intake interview, Sarah commented that Haley was always a pleaser and seemed to defer to other childrens ideas when playing. Sarah also described Haley as a very sensitive child, emphasizing that she overreacts to [AQ]feedback. Sarah further commented that Haley seemed to absorb all sorts of information. For example, Haley recently heard about a tornado warning in another part of the

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country and became fearful that a tornado was about to occur in her city. This worry lasted for several weeks. During the intake interview Sarah commented that she and her husband, Mike, parent in different ways. Sarah described herself as tougher than Mike. However, Sarah indicated that they work closely together as a parenting team. Further, since Haley seemed to have few behavioral difficulties Sarah emphasized that, there is little to manage except Haleys occasional overreactions. Daily communication between home and school was reported. At the beginning of the Grade 5 school term, the school contacted the parents stating that Haley had been subjected to verbal teasing in class and on the playground. This was discovered one day when a teacher observed Haley standing by herself on the playground. When the teacher approached her, Haley was crying and hiding her face. Haley was reluctant to discuss this incident with her teacher. When she returned home, Sarah gently raised the issue, noting that Haley was very quiet and reserved. Eventually, Haley began to cry and informed Sarah that she had been teased since the beginning of the school term (approximately three months earlier). Once this information came to light, the parents and school put an action plan together. Part of this plan included buddying Haley with a Grade 6 student at recess, followed by periodic check-ins with Haleys teacher. As well, follow-up discussions occurred at home on a regular basis. As far as both the teaching staff and parents were aware, there was only one other mild teasing incident. This occurred during a line-up and Haley reported it directly to her teacher. Accordingly, the buddy system was phased out and Haley began going out for recess on her own. Currently, Haleys teachers reported that she plays well when she is involved with just one other student. However, this tends to break down in group play situations as Haley experiences difficulties joining in. In these circumstances, Haley often moves to the periphery and either watches or plays alone. When asked to specify desired outcomes for therapy, Sarah identified the following three goals: 1. to help Haley find ways to engage her peers 2. to help Haley become stronger emotionally, by taking greater risks 3. to help Haley cope with overwhelming feelings and situations.
backgrounD Sarah and Mike are the biological parents of Haley and Jonathon, with Mike employed on a full-time basis. When Jonathon was school aged, Sarah began a part-time position with flexible hours. Sarah reported enjoying her reentry into

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the workforce, although she found herself tired in the evenings. As weekends are often devoted to household management activities, Sarah found that she has less time to play with her children. However, Sarah noted that Mike has really stepped up by taking the children out for walks or to other activities in the nearby community. During pregnancy, Sarah had no significant health problems. Immediately following the birth, Haley was healthy. As an infant and toddler, Haley experienced frequent ear infections. Sarah remembered Haley as an affectionate, observant, and calm infant and toddler. Haleys early motor skills, such as sitting up, crawling, and learning to walk, developed earlier than for most other children. Haley attended preschool, beginning at age three. Sarah recalled that Haley appeared to learn things at about the same rate as other children, but seemed very slow to warm up to new situations. Under these circumstances Haley would cry easily and often refused to join the activity. Haleys reaction to the arrival of her brother, Jonathon, was described as difficult, as she became more clingy and needy of her parents attention. At the point of referral, Sarah and Mike described Haley as a kind and gentle child but also one who seems shy, emotional, irritable, and somewhat unhappy. Their descriptions suggested that Haleys mood varied normally. She could play quietly when asked to do so, and often chose solitary play activities. Haley reported liking most school/learning activities and consistently stated that she would rather stay in and work during recess so that she didnt have to take work home. Sarah was concerned that this was becoming a pattern of avoidance for Haley. During a modified play-history interview, Sarah and Mike indicated that Haley appeared to have a limited repertoire of play activities. She uses her dollhouse and play characters to engage in fantasy play scenarios. Together with her younger brother, Haley has also used dress-up for make-believe play. Although there are children her age that live close by, Sarah and Mike reported that Haley often chose to play with her younger brother, or alone. The exception to this is when her cousins come to visit. Sarah emphasized that Haley always followed the lead of the other children and never became the initiator. This trend was noted throughout the play history as in preschool Haley was described as a follower during play center activities. The play history also revealed that Haley loved art-making activities and often drew about experiences she has had, positive or negative. For example, around the time of the teasing incidents, Haleys teacher found that Haley had drawn several pictures depicting children pushing and fighting. Finally, a discussion about Haleys emotional adjustment through the play history interview indicated that she was clingy and experienced difficulties

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separating when she first entered playschool. Specifically, Haley cried and became uncommunicative for over an hour when Sarah left her for the morning preschool program. This pattern did not abate for approximately three months. Mike recalled that for those occasions when he dropped Haley off at school, Haley seldom fussed and was able to transition to program activities after a few minutes. During the initial parent consultation meeting Sarah and Mike were shown the play therapy rooms, and the therapist provided them with an overview of the play therapy process. This included a discussion of parental roles and their involvement in treatment. Toward the end of the meeting, ideas were jointly discussed concerning ways of preparing Haley for coming to the first session.
iniTial imPreSSionS During the first session Haley sat on the couch, positioning herself close to her mother. Mike sat on a nearby chair and made several light-hearted comments, interjecting humor and comfort into the meeting. Haley appeared shy and reserved, often avoiding eye contact. As discussed in the preparatory meetings, Haley brought one of her stuffed animals along for comfort; during the meeting she focused primarily on this object. Following a warm-up discussion about some of Haleys special activities and interests, the therapist introduced her role as one of helping parents and children, particularly when they have been trying to figure out some tricky feelings. An analogy of feelings being like clouds was provided. Sometimes they blow in, and out again, without anyone hardly noticing them. At other times, they kind of sneak in and stay put, because they need something to push them along. As planned, the parents took this cue and briefly stated that Haley appeared to get similar tricky feelings, and they would like to figure out ways that they, as a family, could move them along. The therapist next inquired when the parents first started to notice the settling of the clouds? Sarah reported that they might have blown in at the beginning of Grade 5, but she didnt really notice them until she learned that Haley had been teased at school. The discussion swung around to include Haleys view of when the clouds thickened. Haleys response was polite but succinct; she quietly stated, I dont know. It seems like theyve been there for a while. Tightly gripping her stuffed dog, Haley joined the therapist for her first look at the playroom. Enroute, Haley inquired about where her parents would be, even though this had been discussed prior to leaving the therapists office. Once in the playroom, Haley tentatively looked around, visually explored some areas of the room. Once she spotted the dollhouse she remarked, I have one almost exactly like this at home. She immediately went to the dollhouse and spent

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several minutes looking through the baskets of characters nearby. Haleys journey was about to begin.

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